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Biomedical subjects

K A Sepkowitz

Publications and source records attributed to K A Sepkowitz.

At least 55 records · Page 3Linked to original sources
PubMed1997

Benefit of two-step PPD testing of new employees at a New York City hospital.

BACKGROUND: Recent concern about nosocomial transmission of tuberculosis has led hospitals to scrutinize employee tuberculin conversion rates. The Centers for Disease Control and Prevention recommends two-step testing of new employees to limit the booster phenomenon. The cost of such a program and its subsequent yield have not recently been examined. METHODS: Employee health records were retrospectively reviewed of persons hired from 1993 and 1994 at St. Clare's Hospital in New York City, all of whom received two-step testing at time of initial employment. RESULTS: Of 262 new employees, 107 (41%) had positive tuberculin results on initial testing. The results of 15 (9.7%) of the remaining 155 patients became positive on two-step testing administered 1 week later. Persons with a positive second test result were significantly more likely to be male or foreign born or to have received previous bacille Calmette-Guérin vaccination. Identification of these 15 persons and exclusion of them from probable subsequent conversion prevented an almost 50% increase in the annual conversion rate at our hospital, from 3.2% to 4.7%. CONCLUSION: Two-step tuberculin testing is an essential means of identifying persons with a baseline positive tuberculin test result, thus allowing accurate reporting of subsequent employee tuberculin conversions.

Adult↗
PubMed1997

Comparison of induced versus expectorated sputum for diagnosis of pulmonary tuberculosis by acid-fast smear.

OBJECTIVE: To evaluate the sensitivity of induced versus expectorated sputum for the diagnosis of pulmonary tuberculosis by acid-fast smear. METHODS: We performed a retrospective review of data on patients with cultures from respiratory secretions that were positive for Mycobacterium tuberculosis. We analyzed data on the 114 patients with positive cultures during a 4-year period in an urban tertiary care academic medical center. RESULTS: Sputum samples had been obtained for 103 of the 114 patients with cultures positive for tuberculosis. Forty-four of the 114 patients were HIV seropositive. Overall 33 of 79 patients (42%) had positive acid-fast smears of expectorated sputum, and 6 of 24 (25%) had positive smears of induced sputum (p = 0.21). When data were analyzed for subgroups by HIV serostatus, there was no significant difference in the results. Estimated cost of sputum induction for 1 year was approximately $45,000. CONCLUSIONS: We found sputum induction to be costly, and induced sputum offered no advantage over routine expectorated sputum for the diagnosis of pulmonary tuberculosis.

Coloring Agents↗
PubMed1997

Does a cheaper mask save money? The cost of implementing a respiratory personal protective equipment program.

OBJECTIVE: To determine the annual cost of implementing and maintaining a respiratory personal protective equipment (PPE) program at an urban hospital. SETTING: St Clare's Hospital and Health Center, a 250-bed hospital in Manhattan that treats 60 to 100 cases of tuberculosis annually. METHODS: Review of Purchasing Department records for all masks acquired by the hospital from 1992 to 1995, and an estimate of administrative time spent developing and implementing the guidelines recommended by various agencies during the study interval. RESULTS: Respiratory isolation was provided for 6,360 to 10,883 days annually during the 4-year interval. Yearly costs for the PPE program ranged from $86,560 to $175,690. Of note, the daily cost for a respiratory isolation day decreased dramatically between 1994 and 1995 ($25/day to $13/day), when the high-efficiency particulate air-filter (HEPA) respirator was used by all staff. The decrease occurred because of lower administrative costs and a sharp decrease in the numbers of HEPA units purchased. Objective measures of worker compliance with HEPA respirators demonstrated the decrease was not due to less HEPA use but rather that employees were using each HEPA unit for several weeks, as recommended. CONCLUSION: We found a significant decrease in cost in the second year of our HEPA program due to increasing employee familiarity with the program. Newly approved, cheaper, but less durable, N-95 masks are unlikely to withstand multiple wearings and may be discarded after a few uses. Thus, cheaper masks may result in a more expensive PPE program.

Cost-Benefit Analysis↗
PubMed1997

Risk of tuberculin conversion according to occupation among health care workers at a New York City hospital.

Concern about the risk to health care workers of occupationally acquired tuberculosis has resulted in extensive and frequently revised guidelines from the Centers for Disease Control and Prevention (CDC). Most recent studies, however, have determined that community, rather than occupational, exposure is the more significant risk for tuberculin conversion. To assess the relative contribution of community versus occupational risk, we reviewed the health records of 1,303 persons employed from 1991 to 1994 at St. Clare's Hospital in New York City, a hospital with a high tuberculosis case-rate. Demographic information included age, gender, postal zone of residence, country of birth, and BCG vaccination status, while occupations were placed into one of five groups. In multivariate analysis, occupation was significantly associated with risk of tuberculin conversion, while postal zone of residence was not. The group that included housekeeping, laundry, and security personnel and the physician-nurse group had the highest conversion rates. After implementation of CDC guidelines, there was a significant improvement in the employee tuberculin conversion rate. At our hospital, occupation was strongly associated with risk of tuberculin conversion.

Female↗
PubMed1997

Risk factors and outcome of human immunodeficiency virus-infected patients with sporadic multidrug-resistant tuberculosis in New York City.

SETTING: An 880 bed university teaching hospital in New York City. OBJECTIVE: To assess risk factors and outcome for sporadic cases of multidrug-resistant tuberculosis (MDR-TB) in persons with human immunodeficiency virus (HIV) infection. DESIGN: In a retrospective cohort analysis, 13 HIV-positive patients with MDR-TB (cases) diagnosed between January 1991 and December 1993 were compared to 31 HIV-infected patients with susceptible or single drug-resistant tuberculosis (controls) diagnosed during the same time period to assess for differences in risk factors and outcome. RESULTS: Risk factors for MDR-TB included homosexual contact as a risk for HIV transmission, prior antiretroviral therapy and Pneumocystis carinii prophylaxis. Fatality rates were 62% for MDR-TB patients and 26% for controls (P < 0.04). The median survival time was 5.8 months for cases and 9.8 months for controls. Risk factors associated with death included multidrug-resistance and CD4-lymphocyte counts below 200. CONCLUSION: Sporadic MDR-TB infection in HIV-infected patients is associated with increased morbidity and mortality compared to infection with susceptible or single-drug-resistant TB. The median survival for HIV-infected patients with MDR-TB in this study is, however, two to three times longer than previously reported in MDR-TB outbreaks.

AIDS-Related Opportunistic Infections↗
PubMed1996

Occupationally acquired infections in health care workers. Part II.

BACKGROUND: Health care workers are at occupational risk for a vast array of infections that cause substantial illness and occasional deaths. Despite this, few studies have examined the incidence, prevalence, or exposure-associated rates of infection or have considered infection-specific interventions recommended to maintain worker safety. OBJECTIVE: To characterize the type and frequency of infections, the recommended interventions, and the costs of protecting health care workers. Part II of this two-part review focuses on infections caused by bloodborne organisms, organisms spread through the oral-fecal route, and organisms spread through direct contact. It also reviews established interventions for controlling transmission. DATA SOURCES: A MEDLINE search and examination of infectious disease and infection control journals. DATA SELECTION: All English-language articles and meeting abstracts published from January 1983 to February 1996 related to occupationally acquired infections among health care workers were reviewed. Outbreak- and non-outbreak-associated incidence and prevalence rates were derived, as were costs to prevent, control, and treat infections in health care workers. DATA SYNTHESIS: Occupational transmission to health care workers was identified for numerous diseases, including infections caused by bloodborne organisms (human immunodeficiency virus, hepatitis B virus, hepatitis C virus, Ebola virus), organisms spread through the oral-fecal route (salmonella, hepatitis A virus), and organisms spread through direct contact (herpes simplex virus, Sarcoptes scabiei). Most outbreak-associated attack rates range from 15% to 40%. Occupational transmission is usually associated with violation of one or more of three basic principles of infection control: handwashing, vaccination of health care workers, and prompt placement of infectious patients into appropriate isolation. CONCLUSIONS: The risk for occupationally acquired infections is an unavoidable part of daily patient care. Occupationally acquired infections cause substantial illness and occasional death among health care workers. Further studies are needed to enhance compliance with established infection control approaches. As health care is being reformed, the risk for and costs of occupationally acquired infection must be considered.

Animals↗
PubMed1996

Occupationally acquired infections in health care workers. Part I.

BACKGROUND: Health care workers are at occupational risk for a vast array of infections that cause substantial illness and occasional deaths. Despite this, few studies have examined the incidence, prevalence, or exposure-associated rates of infection or have considered infection-specific interventions recommended to maintain worker safety. OBJECTIVES: To review all recent reports of occupationally acquired infection in health care workers in order to characterize the type and frequency of infections, the recommended interventions, and the costs of protecting workers. Part I of this two-part review focuses on the historical and ethical aspects of the problem and reviews data on infections caused by specific airborne organisms. DATA SOURCES: A MEDLINE search and examination of infectious disease and infection control journals. DATA SELECTION: All English-language articles and meeting abstracts published between January 1983 and February 1996 related to occupationally acquired infections among health care workers were reviewed. Outbreak- and non-outbreak-associated incidence and prevalence rates were derived, as were costs to prevent, control, and treat infections in health care workers. DATA SYNTHESIS: More than 15 airborne infections have been transmitted to health care workers, including tuberculosis, varicella, measles, influenza, and respiratory syncytial virus infection. Outbreak-associated attack rates range from 15% to 40%. Most occupational transmission is associated with violation of one or more of three basic principles of infection control: handwashing, vaccination of health care workers, and prompt placement of infectious patients into appropriate isolation. CONCLUSIONS: The risk for occupationally acquired infection is an unavoidable part of daily patient care. Infections that result from airborne transmission of organisms cause substantial illness and occasional deaths among health care workers. Further studies are needed to identify new infection control strategies to 1) improve protection of health care workers and 2) enhance compliance with established approaches. As health care is being reformed, the risk for and cost of occupationally acquired infection must be considered.

Ethics, Medical↗
PubMed1996

Community-based outbreaks of tuberculosis.

Numerous recent reports have detailed outbreaks of tuberculosis in hospitals and other congregate settings. The characteristics of such settings, including high concentrations of infectious patients and immunocompromised hosts, the potential for sustained daily contact for weeks and often months, and improper precautions taken for protection, make them well suited for tuberculosis transmission. However, community-based outbreaks, which are the source of much public concern, have not been reviewed since 1964, when 109 community outbreaks were examined. Since few of the characteristics of institutional settings are present in the community, the lessons learned may not be applicable to community-based outbreaks. Furthermore, recent studies with analysis by restriction fragment length polymorphisms have documented unexpectedly high rates of primary disease in certain urban communities, suggesting that our understanding of community-based transmission may be incomplete. We reviewed all reported community-based outbreaks of tuberculosis occurring in the last 30 years to assess the basis of our current understanding of community-based transmission. More than 70 outbreaks were identified, with schools being the most common site. In most, a delay in diagnosis, sustained contact with the index case, inadequate ventilation, or overcrowding was contributory. We conclude that community-based outbreaks of tuberculosis continue to occur and that well-established risks contribute to most outbreaks. Many outbreaks can be prevented or limited by attention to basic infection control principles.

Community-Acquired Infections↗
PubMed1996

Tuberculin skin testing and the health care worker: lessons of the Prophit Survey.

SETTING: Concern about occupationally-acquired tuberculosis continues to grow, even as control of tuberculosis in the USA has improved. Many health care workers have developed occupationally-acquired tuberculosis in recently described outbreaks and several have died. Regulatory agencies are struggling to develop a rational policy that promises both worker safety as well as cost-effectiveness. Future infection control efforts will be evaluated by results of tuberculin skin tests of employees. However, unlike many modern diagnostic tests, the tuberculin skin test is poorly understood, may be unreliable, and requires individual physician interpretation. DESIGN: Review of the British Prophit Survey, conducted from 1933-1944, which involved tuberculin testing of 10,000 young adults, with the goal of defining 'the relationship between tuberculin sensitivity and tuberculous immunity'. RESULTS: Four findings are particularly pertinent to the current debate: 1. job-specific rates of tuberculin conversion and subsequent development of disease; 2. risk of exogenous re-infection among already-tuberculin positive health care workers; 3. rates of tuberculin skin test reversion; and 4. implications of induration size. CONCLUSION: The British Prophit Survey produced a great deal of meaningful information regarding the meaning of a positive tuberculin skin test, a negative test, and a change in tuberculin status. Proper interpretation of this test requires full appreciation of its many idiosyncrasies.

Adolescent↗
PubMed1996

Lung abscess in patients with AIDS.

We identified 31 patients with human immunodeficiency virus (HIV) infection and lung abscess. All patients had advanced HIV disease, and the mean CD4 cell count was 17/mm3 (range, 2-50/mm3). Twenty-two patients (71%) had previous opportunistic infections, and 24 (77%) had previous pulmonary infections. Symptoms at the time of presentation included fever (90% of patients), cough (87%), dyspnea (35%), pleuritic chest pain (26%), and hemoptysis (10%). The microbiological etiology was established for 28 patients, and the pathogens recovered were bacteria (65%), Pneumocystis carinii (6%), fungi (3%), and mixed microorganisms (16%). The pathogens included Pseudomonas aeruginosa (11), Streptococcus pneumoniae (6), P. carinii (5), Klebsiella pneumoniae (5), Staphylococcus aureus (4), Aspergillus species (3), viridans streptococcus (2), Haemophilus influenzae (1), Streptococcus milleri (1), Proteus mirabilis (1), and Cryptococcus neoformans (1). Mycobacterium tuberculosis was not isolated; two patients for whom a microbiological etiology was not established responded to antituberculous therapy. Patients were treated for 2-12 weeks; 25% of the patients received > 4 weeks of therapy. The outcome was poor: 36% of the patients had recurrences, and 19% died. In patients with AIDS, lung abscess is associated with advanced HIV infection, is due to a broad spectrum of pathogens, responds poorly to antibiotics, and has a poor prognosis.

AIDS-Related Opportunistic Infections↗
PubMed1996

Infectious complications of autologous bone marrow and peripheral stem cell transplantation for refractory leukemia and lymphoma.

We aimed to characterize the infectious complications of autologous bone marrow (AuBMT) and peripheral stem cell transplantation (PSCT) in patients with refractory leukemia and lymphoma. We performed a retrospective analysis of all patients (n = 56) with refractory leukemia or lymphoma treated with AuBMT or PSCT at Memorial Sloan-Kettering Cancer Center from January 1993 to July 1994. Records were available in 55, of whom 33 (60%) received AuBMT and 22 (40%) PSCT. Fifteen (27%) developed complicated infections, including 13 (39%) treated with AuBMT and two (9%) with PSCT. Complicated infections were caused by bacterial (11 episodes), fungal (four episodes), and viral (four episodes) pathogens. Five (9%) infections were fatal. In a multivariate model, only duration of neutropenia was significantly associated with development of complicated infection (P = 0.006). Thus, 27% of patients with refractory leukemia or lymphoma treated with AuBMT or PSCT developed complicated infections and 9% died of infection. Prolonged neutropenia was significantly associated with development of infection. Patients receiving PSCT had significantly lower rates of complicated infection, presumably due to the associated shorter duration of neutropenia. Future studies are needed to define the role of PSCT as treatment for refractory neoplastic disease.

Adult↗